ITEM/SERVICE

NUMBER OF DAYS

1.     Routine transportation within Illinois or to facilities normally utilized by Illinois residents

10

2      Supplies/sickroom needs costing less than $100

21

3.     Standard wheel chairs

21

4.     Standard hospital beds

21

5.     Specialty-equipped hospital beds

21

6.     Custom wheel chairs

30

7.     Respiratory equipment

30

8.     Other durable equipment

30

9.     Braces, artificial limbs and other prosthetic devices

21

10.   Custom-built shoes and shoes to which a brace or other corrective device is attached.

30

11.   Hearing aids

30

12.   In-patient hospital physical rehabilitation services

30

13.   Supplies/sickroom needs over $100

30

14.   Transportation to remote facilities outside Illinois and extra-ordinary modes of transportation

21

15.   Physical therapy

30

16.   Speech therapy

30

17.   Occupational therapy

30

18.   Home Health Agency

21

19.   Intermittent services in the home by a registered nurse

21

20.   Private duty registered nurse service in a hospital

10

21.   Dental Services

30

22.   Dental Services for GA/AMI/Refugee Programs

30

23.   Eye Care Services

30

24.   Chiropractic Services

30

25.   Podiatric Services

30

26.   All other items or services requiring prior approval.

30